Download Patient Care Objectives

I.
Patient Care Objectives:
Patients who are diagnosed with cystic fibrosis (CF) are often colonized or infected with
organisms that are resistant to many antimicrobials, which can lead to increased morbidity
and mortality. Examples include gram-negative organisms such as Stenotrophomonas
maltophilia and Burkholderia cepacia. These organisms may be spread from patient to
patient by direct contact with contaminated hands, or less frequently by contact with fomites
or contaminated solutions.
II.
Responsibilities:
UMC physicians, nurses, and clinical support staff follow the requirements of the policy.
Supervisor/Department Manager communicate policy contents to personnel and ensure
personnel competency and compliance with the policy.
Department of Hospital Epidemiology and Infection Control provide education, carries out
surveillance for pathogens of interest and act as a resource for information.
Clinical Scheduling Staff schedule so that their time in the common waiting area is minimized.
III.
Procedure:
A.
In addition to standard measures the following should occur when health care
workers care for cystic fibrosis patients:
1.
Hand Hygiene
• When hands are visibly dirty, contaminated with proteinaceous material,
or visibly soiled with blood or other body fluids, including respiratory tract
secretions, wash hands with an antimicrobial soap and water.
• If hands are not visibly soiled, use an alcohol-based hand rub or wash
hands with an antimicrobial soap and water to routinely decontaminate
hands in all clinical situations.
• Perform hand hygiene whether or not gloves are worn.
• Perform hand hygiene in the following clinical situations:
o After removing gloves.
o Before and after contact with any patient.
o After contact with personal or patient’s:
ƒ Mucous membranes.
ƒ Respiratory secretions.
ƒ Objects contaminated with respiratory secretions.
ƒ Respiratory device after use.
• Ensure ready availability of waterless antiseptic, eg, alcohol-based hand
rubs, or similar dispenser, or similar FDA-approved product in all patient
rooms, pulmonary function testing rooms, and waiting area for patients
and families.
• Only natural nails are permitted for HCWs with direct patient contact.
Refer to Infection Control’s hand hygiene policy.
• No recommendation on wearing rings.
2.
Gloves:
• Wear gloves when caring for patients who require contact or droplet
precautions.
• Wear gloves for handling respiratory secretions or objects contaminated
with respiratory secretions of any patient.
• Change gloves:
After handling respiratory secretions or after handling objects
contaminated with secretions from one patient and before
contact with another patient, object, or environmental surface.
o When moving from a contaminated body site to a clean body site
or to he respiratory tract or to a respiratory device on the same
patient.
o Before and after contact with a patient.
Do not wash gloves and then reuse.
o
•
3.
Gowns:
• Wear gown as defined by standard precautions.
• Wear gowns for patients who require contact or droplet precautions
when close contact with the patient or patient’s immediate environment
is anticipated.
• When soiling with respiratory secretions from a patient is anticipated, eg,
during chest physiotherapy, suctioning or examining a patient known to
have coughing spasms, wear a gown and remove the gown after such
contact and before providing care to another patient.
4.
Masks/Eye Protection:
• Wear mask and eye protection or a face shield to protect mucous
membranes of the nose, mouth, and eyes from becoming contaminated
when splashes or sprays of secretions, body fluids, blood, or excretions
are anticipated during procedures or patient care activities.
• Pediatric CF patients will place on a mask as soon as they enter the
waiting room.
• HCW will wear mask in Pediatric and Adult Outpatient examining
rooms, when seeing MRSA patients.
5.
Sterilization/Disinfection and Care of Equipment:
• Follow published recommendations for sterilization and disinfection of
patient care equipment, particularly respiratory therapy and dental
equipment.
• Clean patient care equipment and devices of visible organic residue (eg,
blood respiratory tract secretions, or tissue) as soon as practical with a
hospital approved detergent or enzymatic cleaner and water before highlevel disinfection or sterilization. Soiled materials that become dried onto
instruments cause disinfection or sterilization to be less effective or even
ineffective.
• Following each use of single patient nebulizers rinse with sterile water, or
0.2um filtered water. Do not use tap, bottled, or distilled water only to
rinse equipment. Air- dry the equipment completely after rinsing.
• Dedicate noncritical patient care equipment (such as thermometers, BP
cuffs, etc.) to patients on contact precautions and disinfect before use by
another patient. Use disposable equipment when possible.
• Disinfect environmental surfaces that have become contaminated with
respiratory tract secretions, eg, during pulmonary function testing, body
plethsmorgraphy, air clearance, and in hospital activity rooms.
• Sterilize or high-level disinfect portable respiratory devices between uses
on different patients.
• Sterilize critical medical and surgical devices and instruments that enter
normally sterile tissue or the vascular system, or through which a sterile
body fluid flows (eg, blood) before each patient use.
•
•
At a minimum, high-level disinfect semicritical patient care equipment
that touches mucous membranes (eg, respiratory therapy equipment,
bronchoscopes) or nonintact skin. Follow disinfection with appropriate
rinsing with tap water followed by 70% to 90% ethyl or isoprophyl alcohol
with forced air drying, or sterile water, or filtered water. Following
rinsing, dry and store the device, taking care not to contaminate the
items in the process.
Low-level disinfect noncritical patient care equipment that touches intact
skin.
6.
Wall Humidifiers
• Follow manufacturers’ instructions for use and maintenance of wall
oxygen humidifiers.
• Change the tubing, including any nasal prongs or mask, used to deliver
oxygen from a wall outlet before or after each new patient’s use.
• Discard disposable items after single patient use.
7.
“In-Line” and Hand-Held Nebulizers:
• Follow the manufacturers’ recommendations on the proper use and care
of all equipment including nebulizers and air compressors.
• Between treatments on the same patient, disinfect, rinse with sterile or
filtered water and air-dry small volume in-line or hand-held medication
nebulizers.
• Ensure proper cleaning, drying, and storage of patient’s mask used to
deliver aerosol therapy according to manufacturers’ recommendations.
• Use only sterile fluid for nebulization and aseptically dispense the fluid
into a nebulizer.
• Use single-dose vials for aerosolized medications when possible.
•
Do not share nebulizers (eg, between siblings).
8.
Pulmonary Function Testing Equipment:
• Do not sterilize or disinfect the internal machinery of pulmonary function
testing machines between use on different patients.
• Use a disposable in-line bacterial filter for each patient performing a
pulmonary function test.
• Disposable mouthpieces are preferred.
• Sterilize, or high-level disinfect, reusable mouthpieces, tubing, and
connectors between uses on different patients or follow manufacturers’
recommendations for reprocessing.
• Clean all horizontal surfaces following testing
9.
Disinfection in Ambulatory Care Settings:
• Follow the same classifications for patient care equipment used in
ambulatory care setting (eg, outpatient medical/surgical facilities) and
home care as used in the hospital setting
o Critical devices require sterilization
o Semicritical devices require at a minimum high-level disinfection.
o Noncritical equipment requires low-level disinfection.
10.
Environmental Surfaces:
• Use a one-step process and an EPA- registered hospital grade
disinfectant/detergent designed for housekeeping purposes in patient
•
•
•
•
•
•
care areas.
Clean surfaces in examining room and around equipment according to
hospital policy and after room is vacated if contaminated with respiratory
tract secretions, eg, from patient with productive cough.
Clean housekeeping surfaces (eg, floors, walls, and tabletops) on a
regular basis and as spills occur or when visibly soiled.
In outpatient areas, clean all horizontal surfaces, equipment, doorknobs,
desktop, and sink in exam rooms after each and every patient.
Follow manufacturers’ instruction for proper use of disinfecting products,
especially the recommended use dilution. Promptly clean and
decontaminate spills of blood and other potentially contaminated
materials.
Use EPA-registered phenolic or quarternary ammonium compound for
disinfecting noncritical surfaces, eg, blood pressure cuffs, therapy vests,
bedpans, and furniture. An alternative is to use 1:100 to 1:500 diluted
household bleach
Disinfect noncritical medical equipment with disinfectant at the use
dilution and contact time of at least 30 seconds.
11.
Microbiology, molecular typing, and surveillance
• Perform respiratory tract cultures/sensitivities in CF patients as clinically
indicated per CFF recommendations:
• Perform culture and sensitivity testing of specimens from cystic
fibrosis patients in the Microbiology Laboratory using the established,
special Cystic Fibrosis microbiology protocol
• Use the B. cepacia Research Laboratory and Repository or another
reference laboratory for molecular typing.
• Perform molecular typing of B. cepacia complex isolates and other
organisms when epidemiologically indicated.
• Perform molecular typing using an appropriate genotyping method. (eg,
PFGE, RAPD-PCR, or Rep-PCR).
12.
Surveillance Strategies:
• Collaborate with the CF center’s infection control team when developing
surveillance strategies and when analyzing and reporting data related to
infection.
• Target B. cepacia complex, S. aureus including MRSA, and P.
aeruginosa including multidrug-resistant and mucoid P. aeruginosa for
surveillance.
• Target other potential pathogens including S. maltophilia, A.
xylosoxidans, or NTM if epidemiologically or clinically indicated.
• Calculate the incidence and prevalence rates of target organisms and
summarize antimicrobial susceptibility profiles.
• Share reports of surveillance summaries of targeted organisms between
the Infection Control Team and CF Care Team at least annually.
• Perform epidemiologically directed environmental cultures in consultation
with infection control team if an environmental reservoir is suspected to
be associated with transmission of pathogens in CF patients.
13.
Inpatient Settings:
•
•
•
•
•
•
•
•
Transmission Precautions
All HCWS must observe standard precautions when caring for patient
with CF
Family members/visitors are to follow the assigned isolation protocol.
If patient’s family brings food in for the patient, the food is to be bagged
by someone wearing gloves and placed in the patient nourishment
refrigerator.
Place CF patients who are infected with MRSA in the sputum are to wear
a gown, gloves, and mask. If MRSA is found in any other site, a gown
and gloves are to be worn.
B. cepacia complex, multidrug-resistant P. aeruginosa, RSV,
parainfluenza virus, or VRE on contact precautions (gown and gloves).
Place CF patients who are infected with adenovirus and influenza on
contact and droplet precautions (gown, gloves, and mask).
CF patients who have a previous diagnosis of non-tuberculosis
mycobacterium and have another positive AFB will NOT be placed on
respiratory isolation (N-95 mask with Stop sign on door).
14.
Room Placement
• Place all CF patients who are infected with B. cepacia complex, MRSA
or VRE in a single patient room that does not share common facilities
(eg, bathroom or shower) with other patients.
• Admit CF patients who are NOT colonized or infected with B. cepacia
complex, MRSA, or VRE to a single patient room whenever possible or
to a room shared with a patient without CF and at a low risk for infection.
• CF patients who sleep in the same room at home may share a hospital
room.
• Place all CF patients who are lung, heart-lung, or liver transplant
recipients in a single patient room in accordance with hospital policy.
Positive pressure and HEPA filtration are not required.
• Ensure that proper dust containment and water leak policies are followed
in areas where CF patients are hospitalized, those patients who have
received lung, heart-lung, or liver transplants.
15.
CF Patient Activity Outside Hospital Room
• Evaluate CF patient activity outside of hospital room in accordance with
hospital policies for specific pathogens. (eg, MRSA or B. cepacia).
• Evaluate CF patients not on transmission-based precautions on a caseby-case basis in accordance with hospital policy. Considerations include
capability of a patient for containing his or her respiratory tract
secretions, age, ability to use proper hygiene, endemic levels of
pathogens in individual center, and adherence to the following practices:
• Perform proper hand hygiene immediately before leaving the room.
Avoid direct contact between CF patients in the hospital unless they are
co-habitants (eg, sleep in the same room at home).
• Use the hospital activity rooms (eg, playroom, exercise room, or
schoolroom) only when no other CF patient is present.
Go to public places in the hospital (eg, cafeteria, lobby) but remain at
least 3 feet from other CF patients in such places.
• Patients with resistant organisms are to wear mask, gown, and gloves
when coming outside their room.
• Instruct CF patients to wash hands before leaving the room.
*After a CF patient has left the hospital activity room, clean surfaces and items
handled by the patient with a disinfectant/detergent.
17.
Respiratory Therapy
• Assume that ALL CF patients could have transmissible pathogens in
respiratory tract secretions even if not yet identified by culture or if
culture results are unkown.
• Perform all respiratory interventions, including aerosol therapy, airway
clearance and sputum collections, in the patient’s room.
• Adhere to standard precautions (using the appropriate combination of
hand hygiene, gloves, gown, mask, and eye protection) when performing
cough-inducing procedures.
• Dedicate airway clearance devices (eg, flutter, acapella, pep device, and
therapy vest) to single patient use during inpatient hospitalization.
• Encourage patients to use their own home airway clearance devices (eg,
flutter, acapella, pep device, and therapy vest) during inpatient
hospitalization in addition to professional chest physiotherapy.
• Dispose of sputum/soiled tissues into covered, no-touch receptacles.
18.
Ambulatory Settings
• Clinic Logistics
o The Health Care Team will be aware of each patient’s
most recent respiratory secretion culture and antimicrobial
results.
o Develop a reliable method, eg, computerized access, to
ensure ready availability of each patient’s most recent
respiratory secretion culture and antimicrobial
susceptibility results.
o Alert other diagnostic areas of patients’ transmission
precautions, especially if they harbor organisms that are a
threat to non-CF patients, eg, MRSA or VRE
o Schedule and manage patients to minimize time in
common waiting areas. Strategies include: a staggered
clinic schedule, placement of patients in an examining
room immediately on arrival at the clinic and keeping the
patient in one examining room while the CF team rotates
through the rooms.
19.
Waiting Area Behaviors
o Instruct patients and family members to observe proper
hand hygiene on arrival at the clinic and when leaving the
clinic.
o Ensure ready availability of dispensers containing a
waterless antiseptic, eg, alcohol-based hand rub or similar
FDA-approved product, in waiting area for use by patients
and families.
o Instruct patients to cough into a tissue and immediately
discard tissue into a covered, no-touch receptacle or toilet
and perform hand hygiene after coughing.
o
o
Discourage handshaking and physical contact between CF
patients to prevent direct and indirect contact with
respiratory secretions.
Maintain a minimal distance of 3 feet between patients in
the waiting area to prevent droplet transmission of
respiratory pathogens.
20.
Organisms –Specific Circumstances
• Observe contact plus standard precautions when caring for a CF patient
who is coughing and infected with epidemiologically important pathogens
(eg, B. cepacia, MRSA, or multidrug-resistant: P. aeruginosa).
• Wear mask when in examining room with Adult or Pediatric patient
with MRSA.
• B. cepacia complex: observe the following for patients infected with B.
complex:
o Segregate from other CF patients.
o Segregate from other CF patients infected with B. cepacia
complex to prevent replacement of one strain with another
potentially more virulent strain.
o Schedule at the end of the clinic session.
o Place in examining room immediately.
o Multidrug-resistant P. aeruginosa: place in examining room immediately.
o Other multidrug-resistant P. aeruginosa: manage CF patients harboring
other multidrug-resistant organisms, such as S. maltophilia or A.
xylosoxidans, according to hospital policy.
• Acid-fast bacilli: observe the following:
ƒ Place CF patients who are AFB smear positive in airborne
infection isolation until M. tuberculosis disease has been
excluded.
Use standard precautions for patients with NTM.
o Place patients with documented M. tuberculosis in
airborne infection isolation until clinically improved and
three AFB sputum specimens obtained at 8-hour or longer
intervals are smear negative.
21
Swimming Pools, Hot Tubs, and Whirlpool Spas Used by CF Patients
• Ensure adequate chlorination.
• For CF patients with central venous catheters in place do not submerge
the catheter under water. Showering may be permitted if precautions
can be taken to reduce the likelihood of introducing organisms into the
catheter, eg, the catheter and connecting device should be protected
with an impermeable cover during the shower.
22.
Psychosocial Impact of Infection Control Guidelines
ƒ Ensure that a clinical social worker is available to address the
psychosocial impact of the microbiologic status and the infection control
guidelines.
ƒ Inform and educate the patient, their identified parent/guardian,
family members about the patient’s microbiologic status and the
psychosocial implications of following the infection control guidelines
necessitated by their microbiologic status.
ƒ
ƒ
ƒ
•
•
•
•
Collaborate with the Child Life Specialist to develop individualized
programs that address the psychosocial impact of the microbiologic
status and infection control guidelines.
Utilize multi-media educational tools (print, audio, video) specific to
infection control education for patients, families and the general public
that are age-specific, read level appropriate and culturally relevant.
Ensure that the patient is able to maintain communication with family and
those outside of the hospital setting via phone or other methods that will
not jeopardize the risk of transmission or acquisition of pathogens.
Educate HCWs, CF patients, their families, and when appropriate,
friends, teachers, employers, and coworkers about the rationale and the
potential psychosocial impact of infection control guidelines.
Develop age- and culture-specific educational tools in written,
audiovisual, and audio format in lay person’s language.
Nurse educators to review with staff involved in care of Cystic Fibrosis
patients.
Monitor adherence to infection control guideline by HCWs, patients, and
family members and provide feedback to the CF team.
24. Healthcare Workers with CF
Provide career counseling to CF patients considering careers in health care and
include:
Education about the modes of transmission of infectious agents. The
HCW with CF will be knowledgeable about the modes of transmission of
infectious agents and the importance of observing standard precautions
at all times.
• Examples of specialty areas (eg, radiology, pathology, primary care, and
social work) where the job duties minimize the risk of transmission or
acquisition of potential pathogens.
• Avoid direct or indirect contact (eg, within 3 feet) with patients who have
CF
• When it is known that a HCW with CF is infected with B. cepacia
complex, segregate the HCW from patients with CF.
When it is known that a HCW is infected with MRSA make work
assignments according to hospital policy or recommendations from
Employee Health and Hospital Infection Control and Epidemiology.
• Make assignments for the care of patients who do not have CF on a
case-by case basis, considering the following health-related factors:
o Frequency and severity of coughing episodes, quantity of
sputum production during these episodes, and ability to
contain respiratory tract secretions.
o Known infection with epidemiologically important
pathogens.
o A HCW’s ability to use barrier precautions and adhere to
infection control guidelines, institutional guidelines,
Centers for Medicare and Medicaid Services, HICPAC,
and CDC Guidelines.
o Evaluate risk of transmission of pathogens between
patients by HCW in the context of specific job.
Advise HCWs with CF to seek guidance concerning
patient care assignments from their CF physician and/or
employee health service, if their health status changes.
Avoid direct or indirect contact with patients who have CF
of those at increased risk of acquiring B. cepacia complex
(e.g. chronic granulomatous disease).
Reference:
Cystic Fibrosis Foundation. (2003). Infection Control Recommendations for Patients with
Cystic Fibrosis: Microbiolog,y Important Pathogens, and Infection Control Practices to
Prevent Patient-to-Patient Transmission. Concensus Conferences, Vol. 24, Number 5,
Supplement, May.